Forms By Form Number

2000-38

   

When an operator decides to make field modifications to approved (permissible) equipment, he shall apply in writing to make such modifications in accordance with 30 CFR 18.81. The proposed modifications shall conform with the applicable requirements and shall not substantially alter the basic functional design of the originally approved equipment. The application along with the plans for the modifications shall be filed with the MSHA Approval and Certification Center, which may examine, investigate and approve the changes.


2000-7

   

Within 30 days of applying for an Mine ID or when there are any changes to the legal ownership structure for a mine, a mine operator must file a Legal Identification Report with MSHA. MSHA uses this information to properly identify persons charged with violating mandatory safety and health standards and in the assessment of civil penalties on those violations. The Office of the Solicitor uses the information to expedite service of documents upon the mine operator.


2000-7

   

A written declaration of an individual or union as the representative of miners for a given operator.


4000-9

   

Operators are required to maintain accurate records of employee exposures to potentially toxic materials or harmful physical agents. Data submitted to MSHA on Form 4000-9 establishes a means by which MSHA can: assure compliance with underground radiation standards; form a database for epidemiological studies; and provide information of cumulative radon exposures.


5000-1

   

All instructors are required to submit to submit to MSHA the names of persons who have satisfactorily completed required electrical training. MSHA uses the form information to issue certification cards to those persons who are qualified.


5000-23

   

Certificate of Training


5000-3

   

30 CFR 49 implements the provisions of Section 115(e) of the Federal Mine Safety and Health Act of 1977. Every operator shall assure the availability of mine rescue capability for purposes of emergency rescue and recovery. In accordance with 30 CFR 49.7 , each member of a mine rescue team shall be examined annually by a physician who shall certify that he or she is physically fit to perform mine rescue and recovery work. The mine operator is required to keep the completed MSHA Form 5000-3 on file for a period of one year.


5000-41

   

All instructors are required to submit to MSHA the names of persons who have satisfactorily completed required mine foreman and pre-shift examiner or hoisting certification training. The 5000-41 is a combined version of the previous 5000-4 and 5000-7 forms. MSHA uses the form information to issue certification cards to qualified persons.


5500

   

Plan administrators annually file this report containing information described in section 103 of ERISA.


7000-51

   

All mines are required to apply for an MSHA mine identification number. An MSHA ID is required for each mine site and must be issued before any operations may begin.


7000-52

   

All independent contractors are required to apply for an MSHA contractor identification number. An MSHA ID is required for each contractor operating a mine site and must be issued before they begin specific activities.


9035CP

   

The application form and other requirements in these regulations are for employers seeking to use nonimmigrants in specialist occupations and as fashion models.


CA-1

   

DFEC CA-1, Federal Notice of Traumatic Injury and Claim for Continuation of Pay/Compensation: This form is used by a federal employee to provide notice of traumatic injury and to claim continuation of pay (compensation). The form must be filed with one's employing agency.


CA-10

   

DFEC CA-10, What A Federal Employee Should Do When Injured At Work: This form indicates the actions a Federal employee should perform after being injured at work.


CA-1031

   

DFEC CA-1031, Letter to Dependants to Verify Claimant Support: This letter requsts information needed to verify support of dependents in compensation entitlement determinations.


CA-1074

   

DFEC CA-1074, Letter to Parents in Death Claim Development: This letter requsts information needed to verify decedent's support of dependent parents in compensation entitlement determinations.


CA-1108

   

DFEC CA-1108, Statement of Recovery Letter with Long Form: Representative's statement of recovery for third-party damage claims.


CA-1122

   

DFEC CA-1122, Statement of Recovery Letter with Short Form: Representative's statement of recovery for third-party damage claims.


CA-12

   

DFEC CA-12, Claim For Continuance of Compensation Under the Federal Employees' Compensation Act: Beneficiaries of deceased federal employees may complete and submit this form to request continuation of compensation under the Federal Employees' Compensation Act.


CA-17

   

DFEC CA-17, Duty Status Report: This form is provided for the purpose of obtaining a medical duty status report for the injured employee.


CA-2

   

DFEC CA-2, Notice of Occupational Disease and Claim for Compensation: This form is used by a federal employee to provide notice of occupational disease and to claim compensation. This form must be filed with one's employing agency.


CA-20

   

DFEC CA-20, Attending Physician's Report: This medical report is required before payment of compensation for loss of wages or permanent disability can be made to the injured employee. This information is required to obtain or retain a benefit.


CA-2231

   

DFEC CA-2231, Claim for Reimbursement Assisted Reemployment, This form is used by private employers to claim partial salary reimbursement for reemployment of an injured Federal employee. One must have a signed Cooperative Agreement with OWCP in order to claim such reimbursement.


CA-278

   

DFEC CA-278, Claim for Reimbursement of Benefit Payments and Claims Expense Under the War Hazards Compensation Act: This form is used to claim reimbursement of benefit payments and claims expense under the War Hazards Compensation Act.


CA-2a

   

DFEC CA-2a, Notice of Recurrence: This form is used by a federal employee to provide notice of a recurrence of a traumatic injury or occupational disease, and to claim continuation of pay or compensation. The form must be filed with one's employing agency.


CA-35

   

DFEC CA-35, Evidence Required in Support of a Claim for Occupational Disease: This form is used by federal employees (and their physicians), supervisors, and compensation specialists to assist them by listing all the backing documentation needed to support an occupational disease claim.


CA-40

   

Form CA-40 is used to designate a recipient of the Federal Employees' Compensation Act Death Gratuity Payment under Section 1105 of Public Law 110-181 (Section 8102a).


CA-41

   

Form CA-41 is used to initiate the claims process for "Claims for Death Benefits" submitted under Section 8105 of Public Law 110-81 (Section 8102a).


CA-42

   

CA-42 is used as the Official Notice of Employees' Death for Purposes of FECA Section 8102a Death Gratuity.


CA-5

   

DFEC CA-5, Claim for Compensation by Widow, Widower, and/or Children: A deceased federal employee's widow, widower, and/or children may use this form to claim work-related death benefits.


CA-5b

   

DFEC CA-5b, Claim for Compensation by Parents, Brothers, Sisters, Grandparents, or Grandchildren: A deceased federal employee's parents, grandparents or representative (custodian or guardian) of minor brothers, sisters, or grandchildren may use this form to claim benefits.


CA-6

   

DFEC CA-6, Official Supervisor's Report of Employee's Death: This form is completed by a deceased employee's official superior or other authorized official of the employing agency when a Federal employee dies as a result of an employment related injury or disease.


CA-7

   

DFEC CA-7, Claim for Compensation: This form is used by a federal employee to to claim compensation for employment-related disability. The form must be filed with one's employing agency.


CA-721

   

DFEC CA-721, Notice of Law Enforcement Officer's Injury Or Occupational Disease: This form is used by law enforcement officers to submit a claim for injury or occupational injury. It is also used by the employing organization to file a report, and by the officer's attending physician to provide a medical report.


CA-722

   

DFEC CA-722, Notice of Law Enforcement Officer's Death: This form is used to report the death of a law enforcement officer, including an attending physician's report. It may also be used to file a claim on behalf of a widow, widower, or children.


CA-7a

   

DFEC CA-7a, Time Analysis Form: This form is used used for claiming compensation, including repurchase of paid leave.


CA-7b

   

DFEC CA-7b, Leave Buy Back (LBB) Worksheet/Certification and Election: This form is intended to accompany Form CA-7, Claim for Compensation, when the employee is claiming leave buy back.


CC-4

   

Individuals who are protected by the contract compliance programs may file a complaint if they believe they have been discriminated against by federal contractors or subcontractors. A complaint may also be filed by organizations or other individuals on behalf of the person or persons affected.


CM-1159

   

CM-1159, Report of Arterial Blood Gas Study: After a coal miner applies for black lung benefits, a complete pulmonary evaluation is authorized in order to determine if the claimant is totally disabled by pneumoconiosis. The arterial blood gas study is one part of the evaluation. The CM-1159 is completed by the physician.


CM-2907

   

CM-2907, Report of Ventilatory Study: After a coal miner applies for black lung benefits, a complete pulmonary evaluation is authorized in order to determine if the claimant is totally disabled by pneumoconiosis. The ventilatory exam (or pulmonary functions study) is one part of the evaluation. The CM-2907 is completed by the physician.


CM-2970

   

CM-2970, Operator Response to Schedule for Submission of Additional Evidence: When the Agency issues a Schedule for Submission of Additional Evidence, the CM-2970 is sent to the coal mine operator to give it the opportunity to agree with or to contest its liability and the claimant’s eligibility.


CM-2970a

   

CM-2970a, Operator Response to Notice of Claim: The CM-2970a is sent with the Notice of Claim when a coal mine operator is identified as potentially liable for payment of benefits. This form gives the operator an opportunity to accept or contest statements about its liability.


CM-623

   

CM-623, Representative Payee Report: Benefits may be paid to a representative payee on behalf of the entitled individual when the beneficiary is unable to manage his or her benefits. The CM-623 is used to collect information from the payee to assure that the beneficiary's needs are met.


CM-623S

   

CM-623S, Representative Payee Report: Benefits may be paid to a representative payee on behalf of the entitled individual when the beneficiary is unable to manage his or her benefits. The Representative Payee Report form is used to collect information from the payee to assure that the beneficiary's needs are being met. The CM-623s is a short version of the CM-623 and is only completed by a relative living with the beneficiary who is the beneficiary’s representative payee.


CM-787

   

CM-787, Physician's/Medical Officer's Statement: Benefits due a black lung beneficiary may be paid to another person on behalf of the entitled individual when the beneficiary is unable to manage his or her own financial affairs. To determine incapability or incompetence, certain medical information needs to be obtained from a physician. The CM-787 is completed by a physician to attest to the beneficiary’s ability to manage benefit payments.


CM-893

   

CM-893, Certificate of Medical Necessity: The CM-893 form is a prescription for durable medical equipment, for home nursing care, or for pulmonary rehabilitation services and is completed by the medical provider. All required objective testing must be included.


CM-908

   

CM-908, Notice of Termination, Suspension, Reduction or Increase in Benefit Payments: The responsible coal mine operator liable for payment, or the operator’s representative, uses the CM-908 to report changes in the amount of the beneficiary's monthly benefits and explain the reason for the change.


CM-910

   

CM-910, Request To Be Selected As Payee: If a black lung beneficiary is incapable of handling his or her affairs, the person or institution responsible for the beneficiary’s care is required to apply to receive the benefit payments on the beneficiary's behalf. The CM 910 is the form completed by a person wanting to be appointed as representative payee.


CM-911

   

CM-911, Miner's Claim For Benefits Under The Black Lung Benefits Act: A miner who applies for black lung benefits must complete the CM 911 (application form). A local Social Security office or Black Lung district office can help in the completion of this form.


CM-911a

   

CM-911a, Employment History: An applicant filing for black lung benefits must complete a CM 911a. This form is used to help determine if the miner worked in the Nation's coal mines, the extent of dust exposure, and who would potentially be liable for benefit payments.


CM-912

   

CM-912, Survivor's Form For Benefits Under The Black Lung Benefits Act: This form is an application for benefits or continuation of benefits by survivors. A surviving spouse, child, parent or sibling must complete this form and send it to the black lung district office. A local social security office or black lung district office can help in the completion of this form.


CM-913

   

CM-913, Description Of Coal Mine Work and Other Employment: The CM-913 form is completed by the applicant when the miner performed non-coal mine work in addition to his coal mine employment. The form is used to compare coal mine with non-coal mine work.


CM-921

   

CM-921, Instructions For Completion of Form CM-921: This form gives instructions for reporting insurance coverage for coal mine operators. The CM-921 is printed and completed by insurance companies.


CM-929

   

CM-929, Report of Changes That May Affect Your Black Lung Benefits: To help determine continuing eligibility of primary beneficiaries receiving black lung benefits from the Black Lung Disability Trust Fund, the CM-929 is completed by the beneficiary to report factors that may affect his or her benefits, including income, marital status, receipt of state workers' compensation, and dependents’ status.


CM-929p

   

To help determine continuing eligibility of primary beneficiaries receiving black lung benefits from the Black Lung Disability Trust Fund who also have representative payees, the CM-929p is completed by the representative payee to report factors that may affect the beneficiary's benefits, and to account for benefits received and expended on behalf of the beneficiary.


CM-933

   

CM-933, Roentgenographic Interpretation: The CM-933 form is used by the examining physician or radiologist to record the results of the diagnostic x-ray. The X-ray is a required diagnostic test used to determine if a claimant has pneumoconiosis.


CM-933b

   

CM-933b, Roentgenographic Quality Rereading: The CM-933b is used by a B-reader to verify the quality of an x-ray film.


CM-936

   

CM-936, Authorization For Release Of Medical Information (Black Lung Benefits): The CM-936 is used by claimants who wish to grant permission to DCMWC to request evidence of medical treatment in support of their claims. The form provides the claimant's consent for medical institutions and private physicians to release medical information to DCMWC.


CM-972

   

CM-972, Application for Approval of a Representative's Fee in a Black Lung Claim Proceeding Conducted by The U.S. Department of Labor: The CM-972 is used by a claimant’s representative to request a fee for legal services performed in connection with a claim for black lung benefits.


CM-981

   

CM-981, Certification by School Official: The CM-981 is completed by school official to verify that a beneficiary’s dependent is a full-time student.


CM-988

   

CM-988, Medical History and Examination for Coal Mine Workers' Pneumoconiosis: After a coal miner applies for black lung benefits, a complete pulmonary evaluation is authorized in order to determine if the claimant is totally disabled by pneumoconiosis. The CM-988 is completed by the physician authorized to perform the physical examination for DCMWC.


EEOICP EE-1

   

EEOICP EE-1, Claim for Benefits under Energy Employees Occupational Illness Compensation Program Act: Applicants use this form to submit a claim for Employee Benefits under the Energy Employees Occupational Illness Compensation Program Act.


EEOICP EE-2

   

EEOICP EE-2, Claim for Survivor Benefits under Energy Employees Occupational Illness Compensation Program Act: Applicants use this form to submit a Survivor Claim under the Energy Employees Occupational Illness Compensation Program Act.


EEOICP EE-3

   

EEOICP EE-3, Employment History for Claim Under Energy Employees Occupational Illness Compensation Program Act: Applicants use this form to submit an Employment History for a claim under the EEOICPA.


EEOICP EE-4

   

EEOICP EE-4, Employment History Affidavit for Claim Under Energy Employees Occupational Illness Compensation Program Act: Applicants use this form to submit an Employment History Affadavit for a claim under the EEOICPA.


EEOICP EE-7

   

EEOICP EE-7, Medical Requirements under the Energy Employees Occupational Illness Compensation Program Act: This form identifies the Medical Requirements documentation required for submission of a claim under the Energy Employees Occupational Illness Compensation Program Act.


EFAST-1

   

Form EFAST-1 is used by filers of Forms 5500 and 5500-EZ who wish to participate in an electronic filing program. EFAST-1 will transmit filer signature and declarations to EFAST so they may be used with secure codes for electronic transmission.


ETA 9081

   

The Nursing Relief for Disadvantaged Areas Act of 1999 (NRDAA) was passed to respond to a very specific need for qualified nursing professionals in understaffed facilities serving mostly poor patients in inner-cities and in some rural areas.


ETA 750A

   

Information provided on the labor certification application by employers seeking to employ foreign workers for permanent or temporary employment in the U.S. permits the Department to meet responsibilities.


ETA 750B

   

Information provided on the labor certification application by employers seeking to employ foreign workers for permanent or temporary employment in the U.S. permits the Department to meet responsibilities.


ETA 9035

   

The application form and other requirements in these regulations are for employers seeking to use nonimmigrants in specialist occupations and as fashion models.


LM-1

   

The LMRDA and the CSRA regulations require that every covered union adopt a constitution and bylaws and file two copies with OLMS, along with a Labor Organization Information Report, Form LM-1, providing certain information about the structure, practices, and procedures of the union.


LM-10

   

Employers must file annual reports on Form LM-10 if they had certain specified financial dealings with their employees, unions, union agents, or labor relations consultants.


LM-15

   

Within 30 days after imposing a trusteeship over a subordinate union, the parent union must file an initial Trusteeship Report, Form LM-15, to disclose the reasons for the trusteeship, when it was established, the financial condition of the trusteed union at the time the trusteeship was established, and other required information. Within 30 days after the end of each 6-month period for the duration of the trusteeship, the parent union must file a semiannual report, on Form LM-15, explaining its reasons for continuing the trusteeship.


LM-15A

   

Form LM-15A must be filed with a semiannual or terminal trusteeship report if, during the period covered by the report, there was any convention or other policy-determining body to which the subordinate union sent delegates or would have sent delegates if not in trusteeship or election of officers of the union which imposed the trusteeship over the subordinate union.


LM-16

   

Within 90 days after the termination of the trusteeship, or the loss of identity as a reporting organization by the trusteed union, the parent union must file a Terminal Trusteeship Report, Form LM-16.


LM-2

   

Every labor organization subject to the Labor-Management Reporting and Disclosure Act, as amended (LMRDA), the Civil Service Reform Act (CSRA), or the Foreign Service Act (FSA) must file a financial report each year with OLMS. Labor organizations with total annual receipts of $250,000 or more must file the revised Form LM-2 for their fiscal years beginning on or after July 1, 2004.


LM-20

   

Every person, including a labor relations consultant, who enters into an arrangement with an employer under which he or she undertakes activities where an object thereof is, directly or indirectly, to persuade employees about exercising their rights to organize and bargain collectively, or obtain information about the activities of employees or a union in connection with a labor dispute involving the employer (except information solely for administrative, arbitral, or court proceedings) must file an Agreement and Activities Report, Form LM-20.


LM-21

   

Every person required to file a Form LM-20 also must file an annual Receipts and Disbursements Report, Form LM-21, if any payments were made or received during the fiscal year as a result of arrangements of the kind requiring the Form LM-20.


LM-3

   

Every labor organization subject to the Labor-Management Reporting and Disclosure Act, as amended (LMRDA), the Civil Service Reform Act (CSRA), or the Foreign Service Act (FSA) must file a financial report each year with OLMS. Labor organizations with total annual receipts of less than $250,000 and more than $10,000 file the Form LM-3.


LM-30

   

Union officers or employees (except employees performing exclusively clerical or custodial services) must file a Labor Organization Officer and Employee Report, Form LM-30, if they or their spouses or minor children have certain interests or dealings related to an employer whose employees their union represents or is actively seeking to represent.


LM-4

   

Every labor organization subject to the Labor-Management Reporting and Disclosure Act, as amended (LMRDA), the Civil Service Reform Act (CSRA), or the Foreign Service Act (FSA) must file a financial report each year with OLMS. Labor organizations with total annual receipts of less than $10,000 must file the Form LM-4.


LS-1

   

DLHWC (Longshore) LS-1, Request for Examination and/or Treatment: This form is given to the injured worker by the employer/insurance carrier to authorize the injured worker to select and be treated by a physician of the injured worker's choice. It is a two-sided form; the employer/insurance carrier completes the front page and the selected attending physician completes the reverse side.


LS-18

   

DLHWC (Longshore) LS-18, Pre-Hearing Statement: This form is mandatory. The parties submit this form to request a claim be referred to the Office of the Administrative Law Judge (OALJ) for a formal hearing. The form lists the disputed issues, resolved issues, witnesses, exhibits and other information relevant to the OALJ hearing.


LS-200

   

DLHWC (Longshore) LS-200, Report of Earnings: This form is required and must be submitted by an employee who is being paid compensation by the Special Fund. The form reports all earnings from employment by the employee during the prior year or other specified period.


LS-201

   

DLHWC (Longshore) LS-201, Notice of Employee's Injury or Death: The employer furnishes this form to an injured worker. The employee or duly appointed representative completes the form to provide written notice of injury or death to the employer. The information from the form is used to assist in determining entitlement to workers' compensation benefits. This form is not to be used in lieu of a formal claim for compensation benefits, or form LS-203.


LS-202

   

DLHWC (Longshore) LS-202, Employer's First Report of Injury or Occupational Illness: This is a required form which is submitted by the employer to report an injury or occupational illness when the employer becomes aware of such injury or illness and/or the injured worker loses one or more shifts of work due to the injury/illness. It is a reporting tool, not an admission of liability.


LS-203

   

DLHWC (Longshore) LS-203, Employee's Claim for Compensation: This form is submitted by the employee or appointed representative making a formal claim for compensation benefits under the Longshore Act due to traumatic injury or occupational illness. A letter delineating the same information may be submitted in lieu of the form. Information from the form will be used to assist in determining entitlement to workers' compensation benefits. The filing of this form does not automatically guarantee entitlement to benefits.


LS-204

   

DLHWC (Longshore) LS-204, Attending Physician's Supplementary Report: This form is submitted by the attending (treating) physician to submit supplemental progress reports relating to the injured employee's treatment for a work-related injury or occupational illness. This report is used to assist in determination entitlement to workers' compensation benefits.


LS-205

   

DLHWC (Longshore) LS-205, Physician's Report on Impairment of Vision: In vision injuries, the treating physician uses this form to report their findings and diagnosis.


LS-206

   

DLHWC (Longshore) LS-206, Payment of Compensation Without Award: This is a required form, submitted by the self-insured employer or insurance carrier to notify the Department of Labor that they have begun payment of workers' compensation benefits to an injured worker. It includes the date benefits begin, the average weekly wage and the compensation rate at which benefits are being paid.


LS-207

   

DLHWC (Longshore) LS-207, Notice of Controversion of Right to Compensation: This is a required form, submitted by the self-insured employer/insurance carrier in response to a claim. This document notifies the Department of Labor and injured worker that no compensation benefits will be paid to the claimant at that time, pending investigation or because they disagree with some part of or the entire claim.


LS-208

   

DLHWC (Longshore) LS-208, Notice of Final Payment or Suspension of Compensation Payments: This is a required form, submitted by the self-insured employer /insurance carrier to notify the Department of Labor and claimant that compensation benefits are being suspended. It shows the payment periods, the benefit rate and the total benefits paid. Failure to comply may result in a civil penalty.


LS-210

   

DLHWC (Longshore) LS-210, Employer's Supplementary Report of Accident or Occupational Illness: The employer uses this form to notify the Department of Labor of changes to the initial injury report (LS-202) filed.


LS-262

   

DLHWC (Longshore) LS-262, Claim for Death Benefits: This form is used to claim death benefits under the Longshore Act or its extensions. The form is submitted by or on behalf of each person claiming to be eligible for death benefits. Information on the form is used to assist in determining entitlement to death benefits. The filing of this form does not automatically guarantee entitlement to death benefits.


LS-265

   

DLHWC (Longshore) LS-265, Certification of Funeral Expenses: This form is submitted by the provider of funeral services to notify the Department of Labor and self-insured employer/insurance carrier of the costs of funeral services for a deceased employee. It is used to determine the amount of funeral expenses allowable in a death case, subject to the maximum allowable.


LS-266

   

DLHWC (Longshore) LS-266, Application for Continuation of Death Benefit for Student: This application is submitted by or on behalf of a dependent student 18 years or older to notify the Department of Labor and the self-insured employer/insurance carrier of the student's intentions to continue education beyond high school. The specific purpose of the form is to request continuation of compensation benefits during the time the student remains in school full-time, not to exceed their 23rd birthday.


LS-267

   

DLHWC (Longshore) LS-267, Claimant's Statement: This report is required. A surviving spouse receiving death benefits must submit this form to state their current marital status and advise whether they have remarried. It is also submitted by or on behalf of a death benefits beneficiary as a student to state and advise whether the student continues to be enrolled in school full-time. The form is used to determine continuing eligibility for compensation benefits. Failure to submit the form may result in termination or loss of compensation benefits.


LS-271

   

DLHWC (Longshore) LS-271, Application for Self-Insurance: This report is required from any employer requesting authorization to become a self-insured employer under the Longshore Act and its extensions. No authorization will be approved unless a completed application form with the required supplemental documentation is received.


LS-274

   

Insurance carriers and/or self-insured employers use this form to report their estimated reserves through a specified reporting period. The form is used by the National Office to determine the adequacy of the insurance carrier’s and/or self-insurer's security deposit.


LS-275ic

   

DLHWC (Longshore) LS-275(IC), Agreement and Undertaking (Insurance Carrier): This report is a mandatory (20 CFR 03.205) pledge agreement that is required from every authorized insurance carrier that is required to post a security deposit whenever they post the initial security or replace or renew any security that is on deposit with the Department of Labor Longshore Division. It is used to assure the carrier’s prompt payment of compensation, medical services supplies, and any other obligations it has under the statutes (30 USC 932 CFR 703.213).


LS-275si

   

DLHWC (Longshore) LS-271(SI), Agreement and Undertaking (Self-Insured Employer): This report is a mandatory (20 CFR 703.205) pledge agreement that is required from any company authorized to be a self-insured employer under the Longshore Act and its extensions whenever they post their initial security deposit or renew or replace any security on deposit with the Department of Labor Longshore Division. It is used to assure the self-insured employer’s prompt payment of compensation, medical services supplies, and any other obligations it has under the statutes (30 USC 932 CFR 703.213).


LS-276

   

DLHWC (Longshore) LS-276, Application for Security Deposi Determination: An insurance carrier authorized to write insurance for payment of compensation under the Longshore and Harbor Workers' Compensation Act, 33 USC 901-950, or any of its extensions must fully secure its payment obligation under the statutes by depositng security in the amount determined by the Office of Workers' Compensation Programs. On annual basis, each authorized carrier (or a carrier seeking authorization) must complete this aplication. The information in this application will help the Office determine the security amount necessary to fully secure the carrier's payment of compensation, medical services and supplies, and any other obligations it has under these statutes.


LS-33

   

DLHWC (Longshore) LS-33, Approval of Compromise of Third Person Cause of Action: The form used by legal representatives of the injured worker, insurance carrier or self insured employer who are seeking the Department of Labor Longshore Division’s Approval of Compromise of Third Person Cause of Action (third party settlement).  The form must be submitted within 30 days of such third party settlements in order to protect the interested parties’ right to credit for payments made in such settlements against their liability for compensation benefits under the Longshore Act and extensions.


LS-426

   

DLHWC (Longshore) LS-426, Request for Earnings Information: This is a Department of Labor letterhead letter sent by the Longshore District Office to an injured worker to request information regarding earnings for the one year prior to the injury.  The form is sent when the Department of Labor receives information from an insurance carrier or self insured employer that compensation is being paid at the minimum rate pending receipt of earnings information.


LS-570

   

Form LS-570 is used by authorized carriers to report the policy of insurance issued for each insured employer. This form is to be sent to the deputy Commissioner in the compensation district indicated by the employer's address.


MSHA 7000-2

   

Mine operators are required to report employment and production information to MSHA using Form 7000-2 for each quarter of operation at the mine.


MSHA 7000-1

   

If an accident, injury or illness occurs at or in conjunction with activity at a mine, mine operators are required to report the circumstances of the incident to MSHA using Form 7000-1.


OSHA 7

   

Any employees or representatives of employees who believe that a violation of a safety or health standard exists that threatens physical harm, or that an imminent danger exists, may request an inspection by using this form to give notice to the Secretary or an authorized representative of such violation or danger.


OWCP-04

   

OWCP-04, Uniform Billing Form: This information is required to reimburse health care providers for services rendered to injured employees covered under OWCP-administrative programs


OWCP-1

   

OWCP-1, Agreement and Undertaking: This form is an Agreement and undertaking for security in the payment of compensation benefits furnishing satisfactory proof to OWCP of the financial ability to pay such compensation benefits.


OWCP-1168

   

OWCP-1168, Black Lung Provider Enrollment Form: The information collected on this form will be used to ensure accurate medical provider information for payment of medical and vocational rehabilitation bills.


OWCP-1500

   

OWCP-1500, Health Insurance Claim Form: This information is required to reimburse health care providers for services rendered to injured employees covered under OWCP-administrative programs.


OWCP-16

   

OWCP-16, Rehabilitation Plan And Award: Injured workers use this form to request the award of monies to cover a rehabilitation plan.


OWCP-17

   

OWCP-17, Rehabilitation Maintenance Certificate: This form is used to claim rehabilitation maintenance payments in accordance with a pre-approved rehabilitation plan.


OWCP-20

   

OWCP-20, Overpayment Recovery Questionnaire: When an overpayment occurs, the U.S. Department of Labor (DOL) is required by law to recover such amount unless recovery of the overpayment may be waived in full or in part. The request for information in this form is authorized by law and is necessary to assist DOL in making the waiver determination. If DOL cannot waive recovery of the overpayment, the financial information in this form will be important to establish the recovery amount and repayment period.


OWCP-44

   

OWCP-44, Rehabilitation Action Report: Rehabilitation specialists use this form to report the change in status of a rehabilitation patient.


OWCP-5a

   

OWCP-5a, Work Capacity Evaluation For Psychiatric/Psychological Conditions: Attending physicians use this form to report on a federal employee's work capacity limitations due to psychiatric/psychological conditions he/she has reported.


OWCP-5b

   

OWCP-5b, Work Capacity Evaluation For Cardiovascular/Pulmonary Conditions: Attending physicians use this form to report on a federal employee's work capacity limitations due to cardiovascular/pulmonary conditions he/she has reported.


OWCP-5c

   

OWCP-5c, Work Capacity Evaluation for Musculoskeletal Conditions: Attending physicians use this form to report on a federal employee's work capacity limitations due to musculoskeletal conditions he/she has reported.


OWCP-915

   

This form is used to claim reimbursement for out-of-pocket medical expenses pertaining to the treatment of an accepted condition covered by the Federal Employees' Compensation Act, the Black Lung Benefits Act, and the Energy Employees Occupational Illness Compensation Program Act of 2000.


OWCP-957

   

OWCP-957, Medical Travel Refund Request: This form is used to claim reimbursement for medically related travel covered by the Federal Employees' Compensation Act, the Black Lung Benefits Act, and the Energy Employees Occupational Illness Compensation Program Act of 2000.


S-1

   

Every surety company which issues any bond required by the LMRDA or the Employee Retirement Income Security Act of 1974 (ERISA) must file the Surety Company Annual Report, Form S-1, with OLMS regarding its bond experience under each act.


VETS-100

   

This veterans' annual report is required by 38 U.S.C. 4212(d) from entities with contracts of $10,000 and with Federal departments or agencies with a number of special disabled and Vietnam-era veterans.


VETS-1010

   

The Form VETS/USERRA/VP-1010 is used to file complaints with the Department of Labor's Veterans' Employment and Training Service under either the Uniformed Services Employment and Reemployment Rights Act or laws and regulations related to veterans' preference in Federal employment.


WH-226

   

This is an application for the authority to employ workers with disabilities at special minimum wage rates under the Fair Labor Standards Act (FLSA), Walsh- Healey Public Contracts Act (PCA), or McNamara-O’Hara Service Contract Act (SCA).


WH-226A

   

This is a supplemental application for the authority to employ workers with disabilities at special minimum wage rates under the Fair Labor Standards Act (FLSA), Walsh- Healey Public Contracts Act (PCA), or McNamara-O’Hara Service Contract Act (SCA).


WH-347

   

The Certified Payroll Report is an optional form for use by contractors and sub-contractors on federally financed or assisted construction contracts in attesting that laborers and mechanics were paid prevailing wages and fringe benefits in accordance with requirements of the Davis Bacon and Related Acts (DBRA) and the Copeland “Anti-Kickback” Act. The properly completed form may be used to provide required payroll information to contracting agencies for review.


WH-380-E

   

Certification of Health Care Provider for Employee’s Serious Health Condition


WH-380-F

   

Certification of Health Care Provider for Family Member’s Serious Health Condition


WH-381

   

The Employer Response to Employee Request for Family and Medical Leave may be used by an employer covered by the Family and Medical Leave Act (FMLA) to satisfy its obligation (whether or not it chooses to use the form) to provide written notification detailing the employer’s specific expectations and obligations of an employee taking FMLA protected leave.


WH-382

   

Designation Notice of the Family and Medical Leave Act


WH-384

   

Certification of Qualifying Exigency For Military Family Leave


WH-385

   

Certification for Serious Injury or Illness of Covered Servicemember -- for Military Family Leave


WH-4

   

The H-1B Non-Immigrant Information Form is used to provide information to the Wage and Hour Division regarding an employer’s compliance with requirements of the H-1B program for non-immigrants working in the U.S.


WH-501

   

The Wage Statement for Migrant and Seasonal Agricultural Workers is an optional form for use by farm labor contractors, agricultural employers and agricultural associations to satisfy their obligation – whether or not they choose to use this form – to maintain individual payroll information and provide it to covered workers as required by the Migrant and Seasonal Agricultural Worker Protection Act (MSPA). The form is available here in English and Spanish to assist the agricultural employer community meet its obligation, insofar as is necessary and reasonable, to provided information in a language common to the workers if the workers are not fluent and literate in English. Contact the nearest Wage and Hour Division District Office to determine the availability of this form in other languages.


WH-501S

   

Spanish-language version of the Wage Statement for Migrant and Seasonal Agricultural Workers.

Versión en español de la Declaración del Sueldo para Obreros Agrícolas Migratorios y Temporeros.
La Declaración de Sueldo para Obreros Agrícolas Migratorios y Temporeros es un formulario opcional para el uso de contratistas agrícolas, patrones agrícolas y asociaciones agrícolas para cumplir con su obligación – elijan o no utilizar este formulario – de mantener información individual de la nómina de pago y proveérlsela a los obreros protegidos por la ley, según los requisitos de la Ley de Protección de Obreros Agrícolas Migratorios y Temporeros (MSPA, en inglés). El formulario está disponible aquí en inglés y español para asistir a la comunidad de los patrones agrícolas a cumplir con su obligación, siempre y cuando sea necesario y razonable, de proveerles a los obreros la información en una forma sencilla. Póngase en contacto con la Oficina de Districto más cercana de la Sección de Horas y Sueldos para determinar la disponibilidad de este formulario en otras idiomas.


WH-516 English

   

The Migrant and Seasonal Agricultural Worker Information Form is an optional form for use by farm labor contractors, agricultural employers or agricultural associations to satisfy their obligation (whether or not they choose to use this form) in providing covered workers written notification of the worker's wage rate(s) and other terms and conditions of their employment, as required by the Migrant and Seasonal Agricultural Worker Protection Act (MSPA). The form is available here in English and Spanish to assist the agricultural employer community meet its obligation, insofar as is necessary and reasonable, to provided information in a language common to the workers if the workers are not fluent and literate in English. Contact the nearest Wage and Hour Division District Office to determine the availability of this form in other languages.


WH-516 Spanish

   

Spanish-language version Migrant and Seasonal Agricultural Worker Information Form.

Versión en español de la Forma de Informes para Trabajadores Agrícolas Migratorios y Temporeros.
El Formulario Informativo para Obreros Agrícolas Migratorios y Temporeros es un formulario opcional para el uso de contratistas agrícolas, patrones agrícolas y asociaciones agrícolas para cumplir con su obligación – elijan o no utilizar este formulario – de proveerles a los obreros protegidos por la ley aviso escrito especificando la(s) tasa(s) de pago del obrero y otros términos y condiciones del empleo, según los requisitos de la Ley de Protección de Obreros Agrícolas Migratorios y Temporeros (MSPA, en inglés). El formulario está disponible aquí en inglés y español para asistir a la comunidad de los patrones agrícolas a cumplir con su obligación, siempre y cuando sea necesario y razonable, de proveerles a los obreros la información en una forma sencilla a los obreros. Póngase en contacto con la Oficina de Districto más cercana de la Sección de Horas y Sueldoes para determinar la disponibilidad de este formulario en otras idiomas.